Individual at Guys Marsh

Investigation into the death of a prisoner
at HMP Guys Marsh in February 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
April 2007
This is the report of an investigation into the death of a man who was found in
his cell at HMP Guys Marsh on 14 February 2006, with a ligature around his
neck. Despite evidence that rigor mortis had set in, healthcare staff attempted
resuscitation but without success. The man was aged 63.
I would like to extend my condolences to the man’s family and to all those
touched by his death.
The investigation has been undertaken on my behalf by two of my
investigators. A clinical review of the healthcare the man received whilst in
custody was conducted by the South West Dorset Primary Care Trust. My
thanks are due to the clinical reviewer and to the Governor and staff of Guys
Marsh for their assistance during the course of the investigation. I regret the
delay in completing this report.
The man’s death was the first self-inflicted death to have occurred at Guys
Marsh. Not surprisingly, therefore, it came as a great shock to both staff and
fellow prisoners. This report shows that the man had close and supportive
relationships with staff and other prisoners at the prison, and that every effort
was made to provide a trusting environment in which he could share his
concerns.
I have made just one recommendation.
Stephen Shaw CBE
Prisons and Probation Ombudsman April 2007
CONTENTS
Summary
The investigation process
HMP Guys Marsh
Key Events
Issues
Recommendations
SUMMARY
The man who died had been sentenced to seven years imprisonment for the
attempted murder of his neighbour. At the time of his death, he had served
just under two years. It was the man’s first time in custody.
On reception into prison on remand in February 2004, the man disclosed that
a year before he had attempted to kill himself by placing a shotgun in his
mouth, but could not go through with it. Shortly before sentencing, he told
staff that if he received a long term of imprisonment he would commit suicide.
After spending some time in other prisons, he was transferred to HMP Guys
Marsh on 16 November 2004.
The man was taking a number of prescribed medications for the conditions he
suffered from, including diabetes, heart disease and asthma.
On 13 April 2005, the man appeared depressed. He was tearful and
expressed fears that he would die in prison. An F2052SH document (a form
used by prison staff to monitor prisoners at risk of suicide or self harm) was
opened. The man told the doctor that he was feeling low and that there was
no future for him. The F2052SH document was closed three days later after
the man appeared more settled.
Throughout the man’s time at Guys Marsh, he expressed concerns to staff
about his elderly mother’s poor health and worried that his victim had begun
legal proceedings against him for compensation. He was also anxious about
the possibility of not being able to return to his home area after release.
Although it was known that the man was suffering from depression, staff felt
that he was able to talk about issues that were troubling him. He had formed
supportive relationships with both staff and fellow prisoners,
On 14 February 2006, shortly after his cell was unlocked in the morning, the
man was found with a ligature around his neck. Although rigor mortis
appeared to have set in, healthcare staff still attempted resuscitation.
INVESTIGATION METHODOLOGY
1. Two senior Investigators from my office carried out the investigation
into the man’s death.
2. Notices were displayed throughout HMP Guys Marsh informing staff
and prisoners of the investigation and inviting them to contact the
investigators should they wish.
3. My colleagues visited the prison over several days. They met with the
Governor and Deputy Governor, and with the prison’s Family Liaison
Officer. They interviewed a number of staff and prisoners. They also
spent time on the man’s residential unit and saw the cell in which he
died. The investigators were given access to all his prison records,
including his medical records. The prison’s Independent Monitoring
Board and the local branch of the Prison Officers’ Association were
given the opportunity to raise any issues surrounding the man’s death.
4. The clinical reviewer was asked to provide a clinical review on behalf of
South West Dorset Primary Care Trust. Healthcare staff at Guys
Marsh were interviewed jointly by my investigators and the clinical
reviewer.
5. My investigators spoke with Dorset Police who were acting on behalf of
the Coroner. The police confirmed that they had no concerns about
the circumstances of the man’s death. On completion of my report, a
copy will be sent to HM Coroner to assist him with his enquires into the
man’s death.
6. One of my Family Liaison Officers contacted the man’s family at the
beginning of this investigation. I hope that this report addresses any
concerns they may have.
HMP GUYS MARSH
7. Guys Marsh is a category C training prison and young offender
institution. It originally opened as a borstal in 1960. The prison has
grown considerably over the years and is modern in design.
8. The prison has nine residential units. Jubilee House, where the man
was located, is one of two units in the prison for adult prisoners on the
enhanced level of the prison’s incentives scheme. It was opened in
2002 and is capable of holding up to 40 prisoners in single cells. There
are two landings made up of 20 cells on each. All cells are of a good
size and have en-suite shower room facilities. The unit has a laundry
and an association room for recreation and dining. It is staffed daily by
two officers and managed by a Senior Officer.
9. As part of the prison’s strategy to alleviate distress that could lead to
thoughts of self harm, a Listener scheme operates on a 24 hour basis
for prisoners in need of support. The scheme is a peer support
system, with each Listener receiving training from the local Samaritans.
Listeners wear badges to identify themselves and a prisoner should be
able to talk to a Listener whenever they feel the need.
10. In the introduction to her report of an unannounced inspection of Guys
Marsh in October 2004, HM Chief Inspector of Prisons, Ms Anne
Owers, said:
”Overall, Guys Marsh was a prison that was liked by both staff and
prisoners: it was in general a safe and respectful environment. It was
clear that there had been recent improvements both to the physical
environment and to elements of the decency agenda. Eighty-seven
per cent of prisoners said that there was a member of staff they could
speak to about a problem: only 18% had ever felt unsafe.”
KEY EVENTS
11. On 24 February 2004, the man who is the subject of this investigation
appeared before magistrates, charged with the attempted murder of his
neighbour two days earlier. A Suicide/Self-harm warning form was
opened on the man by a Prisoner Custody Officer, based on
information supplied by Dorset Police. It stated that the man seemed
depressed and when asked how he felt, said he felt “gutted”. The man
also said he would feel better once he arrived at prison because of his
previous occupation in a custodial environment.
12. The man was remanded in custody and taken to HMP Dorchester. On
reception, he was seen by a healthcare worker who completed a First
Reception Health Screen form. The man was asked about his physical
health. Although he said that he had several worries about his general
health, these were not specified on the form. He said he was suffering
from a foot ulcer and was taking a number of medications for medical
conditions including diabetes and asthma.
13. When asked about his mental health, the man said he had attempted
suicide in 2003 by placing a shotgun in his mouth but could not go
through with it. Although he answered “yes” to the question “Do you
feel like hurting yourself at the moment?” he said he was not feeling
suicidal.
14. A Cell Sharing Risk Assessment was also completed. As the man had
been charged with a violent offence and said that he got frustrated, he
was initially assessed as medium risk to other prisoners. This meant
that there was no immediate risk but the situation would need to be
reviewed regularly. However, after he was seen by a member of the
Healthcare Team, he was re-assessed as presenting a low risk.
Nevertheless, due to the nature and seriousness of the charge, it was
decided he should spend his first night in custody in the healthcare
centre as a precaution.
15. On 25 February, the man was prescribed seven types of medication.
An entry in his medical record that day reads, “May need watching,
very despondent at his situation. No suicidal thoughts at the moment.”
16. On 2 March, the man was transferred to HMP Winchester. He was
interviewed as part of the induction process, and the officer noted in
the Record of Events that he was “confused and in a state of shock.
Numerous domestic problems i.e home, pets, aged mother.”
17. On 16 March, the medical record noted that the man was worried about
other prisoners finding out about his previous occupation. He himself
recognised two prisoners that day.
18. On 27 March 2004, an entry in the Record of Events described the
man as being tearful and, although not suicidal, he said that if he
received a significant prison sentence he might feel differently.
19. On 2 April, an officer noted in the man’s Record of Events that he had
been “crying profusely”, and was concerned about his elderly mother
and his dogs. He said that he would not harm himself but, if his mother
died and he lost his dogs, he would have nothing to live for and would
“do it.”
20. On 13 April, a Senior Officer (SO) noted in the Record of Events that
the man said he had a couple of problems with other prisoners but had
managed to cope. He told the SO that, if his mother died whilst he was
in custody, he would kill himself. Over the following months, several
entries in the man’s history sheets and medical notes record him
feeling tearful and worrying about his mother. However, during the
summer of 2004, a number of more positive comments were made
indicating he was working well and being both polite and helpful to
staff.
21. However, this period of relative stability for the man appears to have
been interrupted by his subsequent appearance at court. On 16 July, it
was recorded on his Prisoner Escort Record that he was placed on a
five minute watch after he told Crown Court staff that he would commit
suicide if he received a substantial sentence. He added that he would
assault a member of staff so that he would be taken to the segregation
unit and would be able to kill himself there. The man was observed by
staff every five minutes whilst he was at court. He was convicted of
attempted murder that day but sentence was adjourned for reports. On
return to Winchester, no F2052SH (a self-harm monitoring document)
was raised. The man was admitted to the healthcare centre for
observation of his diabetic symptoms as he had not eaten for two days.
22. Over the following days, two entries were made by healthcare staff with
regard to the man’s state of mind at this time. On 17 July 2004, a
healthcare officer at Winchester recorded in his medical record that he
had:
”Spoke at length to this man. Mood remains low and very tearful at
times. He denies that he is actively suicidal in that he has made no
plans, does not think about it as a very real option and has not thought
about the method. He is adamant that being in healthcare is
detrimental to his mental state - wants to be in a single cell, get back to
the wings to the people he knows. I am aware of concern expressed
by others about this man’s state of mind - believe mood is objectively
low and has been for 4 months - therefore risk of self harm is moderate
- believe he should return to wing where he knows people and feels
secure.”
23. The following day it was recorded that:
”I feel he [the man] is at some risk from locating back to a single
cell. I did not commence a 2050SH as felt it would be detrimental to
him and push him even lower. I do believe in holistic approach and his
well being, currently poor, does have a direct effect on his thought
process, reasoning and mood. His prospects are poor and he is in a
single cell on the house block. I do not believe a risk of suicide is
limited to only those people who show obvious signs of mental illness.
Despair is very relevant in the case of suicide. I believe a careful
assessment should be made, with serious consideration given as to his
sentencing next week and being in a single cell.”
24. On 19 July 2004, an F2052SH was opened by the medical officer at
Winchester. It stated that the man was tearful, depressed and
vulnerable, although he denied being suicidal. It recorded that there
should be regular observations, that he should share a cell, and that he
should have access to the Samaritans. The support plan which should
have been devised to support the man through his vulnerable period
read merely, “Landing staff, Listeners.” A member of the healthcare
team and doctor agreed that, although the man denied having suicidal
thoughts, he was vulnerable to tearful episodes. At a review
undertaken on 22 July, it was considered that it was too early to close
the form. However, after a review a week later on 5 August when it
was noted that the man said he would “probably die in prison of natural
causes and not by his own hand as his mother would not cope”, the
F2052SH was closed.
25. A psychiatric report was prepared for the court by Wessex Forensic
Psychiatry Service. It said that there was no evidence the man was
suffering from mental illness at the time the offence was committed,
and that he did not have a mental illness requiring treatment.
However, it concluded: “It will be important for the man’s mood to be
monitored, either in prison or in the community and I would advise that
a referral be made to a visiting psychiatrist should there be significant
concerns with regards to low mood and risk to self.”
26. On 15 October, the man was sentenced to seven years imprisonment.
His prison records described him as feeling low and upset as his
defence team had told him he would “walk”. He appeared to be more
settled after talking to staff and a Listener.
27. On 16 November 2004, the man was transferred to HMP Guys Marsh.
On arrival, a Cell Sharing Risk Assessment was completed. It
recorded that the man presented no problems, but was a mature man
who might find it hard to cope with his first time in prison. The man
was assessed as presenting a medium risk to others. He was given a
cell on Cambria House. An entry in the Record of Events recorded that
the man had no immediate problems except the need to keep in touch
with his elderly mother.
28. During a Further Reception Health Screen completed on the day of the
man’s transfer to Guys Marsh, and contrary to his reception health
screen at Dorchester, he said that he had never previously attempted
suicide.
29. On 1 December 2004, the man received a letter from his Probation
Officer in the community. He was advised that the Victim Liaison
Officer was seeking to have a condition attached to his licence which
would exclude him from his home area on his release.
30. On 30 December 2004, due to his good behaviour, the man moved
from an ordinary residential unit in Guys Marsh to Jubilee House, one
of the two enhanced units for prisoners at the peak of the Incentives
and Earned Privileges Scheme (IEPS). The man was described
variously by staff as being polite, having a good sense of humour and
keeping himself to himself.
31. On 10 April 2005, the man’s Wing History Sheets recorded that he had
become very quiet again, and on 13 April 2005, an F2052SH was
opened by an officer. It recorded that the man was feeling very down
and tearful and that he was not coping well with prison. He said he felt
he would die in custody. Although it was not Guys Marsh’s policy to
allow prisoners on open F2052SHs to remain on Jubilee House
because of the minimal staff supervision and prisoners being in cells
alone, the decision was taken that the man should be supported and
monitored hourly on Jubilee House. The man was said to be happy to
stay on Jubilee and told staff that he did not wish to see a doctor.
Although he was referred to the healthcare centre, no healthcare
assessment was recorded in the F2052SH.
32. An entry in the man’s medical record on 13 April, states that he was
tearful and upset and that, after coping for 13 months, he was now
feeling low. The man talked at length with an officer on the house
block and agreed to see a doctor the next day.
33. On 14 April, he met with the doctor. The man’s medical record states
that he was upset, feeling low and tearful. He said he felt that he had
no future at the age of 63, although he was currently not feeling
suicidal. The man said, "if I had not done it in Dorchester I would not
do it here, I don't want my mum to know that I have taken my life
away." The doctor recorded that the man had good eye contact, and
that his mood was normal and thoughts were clear. The man said he
did not want counselling but agreed to take an anti-depressant. The
doctor decided that he was to remain on hourly watch and was told
help was available should he go through a crisis. The man replied "I
won't do anything like that."
34. A case review of the man’s F2052SH took place on 16 April. It was
noted that he remained upset on occasion but had said he was not
going to hurt himself in any way. The man talked about being brought
up to deal with his own problems and that he found it difficult when
faced with a difficulty he could not solve himself. After reassuring the
man that he should communicate with staff or speak to a Listener if
necessary, the decision was made to close the F2052SH.
35. Through the remainder of 2005, it was recorded that the man continued
to make good progress. He became happier, although on occasions
he would suffer setbacks as a consequence of circumstances such as
his mother illness. He also received a letter from his victim’s solicitor
advising him that a civil claim for compensation was going to be made
against him.
36. On 2 January 2006, the man applied for Release on Temporary
Licence (ROTL) in order to visit his mother in a local nursing home.
The application was granted and an escorted visit took place on 14
January 2006. The man was said to have been happy that it went well.
37. On 28 January 2006, his wing record noted: "Another steady period
keeps plodding along doing the wing Laundry and model making.
Never gives staff any cause for concern.”
38. In early February, the man wrote a letter to Inside Time, the national
newspaper for prisoners, with reference to an article that had appeared
about re-offending being one of the Government’s core priorities. He
wrote that, even though he had led a law-abiding past, he was
dreading his eventual release. He expressed anxiety at having been
told by the Probation Service that he would be banned from his home
area until at least 2009, even though his family lived close to him and
they were his only relatives. He commented, “I now need a bit of
looking after. Yet upon release I will be going to an area I know
nobody, after the bail hostel.” He sought reassurance asking, ‘Am I a
normal type of prisoner? My worries make me feel that “I will be back”,
going out with no home, no contacts or family …’ The reply from the
newspaper was posted a day before his death. As a consequence, the
man never saw it.
39. On 10 February, the man placed his usual weekly canteen order (an
order via the prison shop) for model making equipment, phone credits,
toiletries and snacks.
40. At 5:42pm on 13 February, the man made his usual daily telephone call
to his mother. The call was relatively brief and was an exchange of
news. At one point, the man’s mother said that she would be visiting
her son in late February and the man confirmed that this was correct.
The conversation was concluded with the man telling his mother that
he would catch up with her the following day.
41. A fellow prisoner on Jubilee House, told my investigators that the man
spent from about 6:45pm to 7:30pm in his cell drinking a cup of tea and
chatting. The fellow prisoner described the man as seeming to be “his
normal self”.
42. The night patrol operational support grade (OSG) said that he had
worked on nights on Jubilee for about three and a half years. Prior to
that, he had been a Senior Officer at Guys Marsh for five years. He
arrived at work on the evening of 13 February 2006 at approximately
8.30pm. He said that he had a handover with the officer in charge of
Jubilee House and nothing of note was brought to his attention. He
then proceeded to check that the cells were locked. He said that this
would have involved opening the cell door flap to see if a prisoner was
there before moving on. The night patrol OSG said that he could not
recall seeing the man that night as he did not know him (or any of the
other prisoners) by sight or name, but that the man must have been
there as the roll was correct. Asked about the way he usually carried
out his duties, the OSG replied, “there’s no reason why I should speak
to them at all unless they have a problem during the evening.”. He saw
his role as satisfying himself that the house block was secure and the
roll correct.
43. The night patrol OSG was asked by my investigators whether he had
seen the man the evening before and on the morning of 14 February.
He replied that he was unable to remember events on the actual days
so he could only say what he would normally do rather than what he
actually did. He said he did not normally engage in conversation with
prisoners on the unit unless they rang their bell. In practice, a prisoner
ringing his bell was “very, very rare”.
44. The night patrol OSG said that during the evening he would have gone
around the unit a number of times in order to complete routine patrols
using a hand-held pegging device. (This registers on an electronic
clock to ensure that regular checks of the wing are being made.) He
said that on the morning of 14 February 2006 he checked to ensure all
prisoners were present and, although he could not remember seeing
the man, he was satisfied he must have seen him and the roll was
reported as being correct. However, copies of the pegging reports
subsequently obtained by my investigators reveal that there is no
evidence of pegging having taken place on the first floor of Jubilee (the
two’s landing) where the man was located.
45. The night patrol OSG said that one of the duties of the night patrol on
Jubilee would be to change the videotape for the CCTV system
covering the corridors. This was done by removing the tape from the
machine, placing it in a box and inserting another tape. This would
normally be done between 6:30am and 7:00am and the tape would run
until the next morning. The OSG said that on the morning of 14
February, at about 6.30am, he noticed that the machine had not been
recording during the night so he switched it on at that point.
46. An officer, who was starting his day shift, took over from the night
patrol OSG on 14 February. He told my investigators that he did not
normally work on Jubilee but had been designated an early start there
until the day staff arrived. He arrived at Jubilee House at
approximately 7:36am. He was informed by the night patrol OSG that
the roll was 40 and, after securing his bag in the office, proceeded to
do the count himself. He said that whilst checking the two’s landing, on
which the man’s cell was located, there were a number of cells where
he had to tap on the door to get the occupant’s attention in order to
satisfy himself that they were present. He said he did not notice
anything different or suspicious. Having looked in each cell for its
occupant and noticing nothing untoward, he returned to the office and
phoned the roll number through at approximately 7:44am. He then
went to his usual place of work in Cambria House.
47. Another officer who did not usually work on Jubilee house block was
assigned to work there for the day. At interview, he said that he arrived
on the house block at about 7:37am on the morning of 14 February
2006 and noticed on the CCTV that the other officer who was starting
his day shift was carrying out the morning count. The second officer
said that he started to carry out daily office checks and that, after a
short time, the other officer arrived in the office, signed for the roll and
then left. A senior officer (SO) arrived on the unit at about 7:55am and,
shortly after this, permission was given for the prisoners to be
unlocked. The officer assigned to Jubilee house block that day said he
went to unlock the two’s landing whilst the SO unlocked the ones
landing (the ground floor). The officer assigned to the house block said
he unlocked the cell doors by turning the master lock on each, but he
did not push them open or look through the observation panels of each
door as he was unlocking them. Asked at interview whether it was
normal to unlock without seeing the occupant, he replied that it was
indeed normal given that the morning number count had already been
done. After taking a few minutes to unlock all the cells on the landing,
including that of the man who died, he returned to the office.
48. A prisoner on Jubilee, told my investigators that the man was usually
one of the first prisoners to be up and about in the morning. Not having
seen him that morning, the prisoner went to the man’s cell, noting his
cell door was slightly ajar, and knocked at the door. As there was no
reply, he walked into the cell. The bathroom door which is to the left as
one enters the cell was open outwards, so that the prisoner could not
see the bed. When he pushed the door back, he saw the man. He
touched the man and found him “stone cold”. He jumped back and
asked another prisoner to tell the officers.
49. The officer assigned to Jubilee house block said that no more than five
minutes after he had finished counting the landing, the other prisoner
on the two’s landing, appeared in the house block office and said that
there was someone hanging in a cell upstairs. Both the officer and the
SO ran there and saw the prisoner who found the man standing
outside cell 2-35 in a distressed state. The SO entered the cell and
saw the man in a crouching position, under the window with one arm
on his bedside locker and a ligature around his neck tied to the
window.
50. The SO told my investigators that there was no movement from the
man and his skin was a greyish colour. The SO bent towards the man
but could not detect any breathing. The office assigned to the house
block that day removed the ligature from the man’s neck. He
commented at interview that he did not take ligature scissors with him,
but the ligature was surprisingly loose and easy to remove. It was not
clear what material the ligature was made from but it appeared to be
black webbing. The SO noticed afterwards that there was another
ligature tied much tighter around the man’s neck which appeared to be
some sort of wire. Both officers described the man’s skin as feeling
cold and clammy.
51. At 8:08am, the SO called for emergency assistance on his radio, and
asked the prisoners who were milling around to go back to their cells.
He did not start Cardio Pulmonary Resuscitation (CPR) as, in his
opinion, the man was clearly dead. An ambulance was called at
8:14am.
52. A healthcare officer (HCO) arrived from the Healthcare Centre a few
minutes later, having received an emergency call on his radio. He
noted that there were no signs of breathing, could not feel a pulse and
the man’s eyes were fixed and slightly dilated. The HCO moved the
locker from under the man’s arm, but the arm remained in a fixed
position. A staff nurse arrived and together they attempted to open an
airway but were hampered by rigor mortis. They applied oxygen and
attempted to place the man flat to start CPR, but were unable to do so.
An ambulance crew arrived at 8:23am. They could find no signs of life,
but applied an ECG in order to detect a trace. No trace was detectable
and the man was pronounced dead at 8:30am. They agreed there was
nothing further they could do and left the prison at 8:53am.
53. The staff nurse was asked at interview by the clinical reviewer about
the attempt to resuscitate the man. He said that the man was clearly
beyond help, but as a nurse he was not able to pronounce death and
would have been horrified if he missed an opportunity to help the man.
In retrospect, however, he felt that their attempts were futile.
54. During Dorset Police’s initial enquiries at Guys Marsh, a detective
sergeant (DS) explored the possibility of whether access had been
gained to the man’s cell at any time during the preceding night. Like
most other prisons, Guys Marsh operates a system whereby night
access can only be gained by a member of staff with the use of a cell
key sealed in a key pouch, which in turn has its own security reference
number.
55. The DS discovered that on 14 February 2006, the seal number on the
key pouch for Jubilee House did not tally with the record held in the
security office. However, the police established that, whilst the paper
record kept in the Governor’s safe had been updated with the new seal
number, the record kept in security had not been updated because of
staff annual leave and other commitments. The police accepted the
explanation. My investigators spoke to an officer who was responsible
for carrying out the key audit. His account corroborated the police’s
conclusions.
56. A closed circuit monitoring system had been installed in Jubilee House,
but there were no written protocols for staff to follow in terms of
operating the system or auditing its effectiveness. The CCTV
recording system on Jubilee had not been switched on the day before
the man’s death was discovered. It was turned on again in the morning
by the night patrol OSG, shortly before he left Jubilee House having
finished his shift. Videotapes show the officer starting his day shift
looking through the observation panel of each cell, including that of the
man who died, and then moving to the next. The police concluded that
there had been no third-party involvement in the man’s death.
57. A post mortem examination was held on 15 February. It concluded
that the cause of death was hanging. No drugs were detected in the
man’s blood.
58. On behalf of South West Dorset Primary Care Trust (PCT), a clinical
reviewer conducted a clinical review of the healthcare the man
received whilst in custody. He noted that, although the man’s use of
anti-depressants had not been reviewed, he did not think that this had
contributed towards his death. He commented on the resuscitation
attempts on the man. He noted that the PCT should review its
resuscitation policy to ensure that staff, “are not placed in the invidious
position of having to perform it in inappropriate circumstances.” I
entirely share that view.
59. My investigators spoke to a number of prisoners and staff at Guys
Marsh about the man. Many of the prisoners who had known the man
spoke of him as being a kind man who had time for other prisoners.
He had good relations with staff on the unit, but was also someone who
was known to be a bit grumpy first thing in the mornings. Occasionally
he would appear a little down, but then he would crack jokes and it
would seem to blow over. One prisoner told my investigators that,
when reading an obituary in a newspaper, he would joke that the dead
person had “stolen his turn”. One of the prisoners told my investigators
that the man would say he was going to leave a big surprise in his cell,
and he would “sort of laugh and chuckle about it”, but no-one expected
him to hang himself.
60. Another prisoner described chatting frequently with the man, whom he
described as “miserable, but likeable”. They would engage in banter.
The man talked to him about his concerns that his victim was pursuing
a legal action against him which “would have resulted in the man losing
everything he had worked his life for, his house, his land, his freedom,
they were even talking about putting a banning order on him,
preventing him going back to his home, that was his life!” He said that
the man felt helpless being in prison.
61. Prisoners in the cells nearest to the man were asked whether they had
heard noise from the cell before he was found. One prisoner, who was
in the cell next to the man, said that the night before his death he did
not hear the man making matchstick models in his cell as he normally
did. Another prisoner, also in an adjacent cell, remarked that, during
the early hours of 14 February 2006, he was awoken at about 3:00am
by some banging and at about 4:00am he said he definitely woke up
after he heard what sounded like someone hitting a bit of wood or a
cupboard. A prisoner on the unit also said he was woken at about
4:00am by the night officer putting on his light and slamming his door
hatch.
62. A prisoner, who had recently been moved from Jubilee house block,
spoke to my investigators about the concerns the man had. Although
he had moved to another house block, Jubilee staff were happy to let
him visit regularly and chat with the man. He described the man’s
mood as up and down and said that the man felt depressed because of
the civil proceedings his victim had begun. He said the man was
constantly mulling over the issue of his property and what would
happen if his house and land were taken away. He described the man
as panicking about not being able to return to his home and not seeing
his mother. He worried about his mother’s poor health and receiving
letters from solicitors. They would chat in the laundry room in Jubilee
House and the man would say, “I’m pissed off with, fed up with these
letters, this bloke he’s after my house, he wants this, he wants this, my
poor mum ...” The prisoner who had been moved from Jubilee house
block said he would try to calm the man down. He said the man would
feel better once he had spoken to his mother and his sister on the
telephone.
63. The man told the prisoner who had recently moved house blocks that
he was going to “do myself in”, and the prisoner who had moved said it
had got worse after he had been given a visit to see his mother. The
prisoner said he would tell the man who died not to be silly and try to
distract him by talking about a television programme, playing chess or
talk about making matchstick models. The prisoner said that he had
seen the man a day or two before his death. The man had asked the
prisoner when he would be visiting Jubilee again, and the prisoner had
replied that he would probably be over at the weekend. The man had
said, “Oh right.” The man had seemed normal to him. The prisoner
said that the man had built up good relationships with staff and he
could talk to them when he felt down, especially another prisoner
friend, the Braille workshop instructor, and another officer. He
described the other officer chatting with the man to keep him occupied
and motivated. He felt that, had the officer been on duty the day before
the man hanged himself, he might have noticed that the man was not
quite his normal self and been able to talk him round. The prisoner
who had moved to another house block told my investigators that, if he
was particularly concerned about the man, he would mention it to the
officers or the man’s other friends so they could keep an eye on him.
He described the staff at Guys Marsh as “very good and helpful,” but
he felt that night staff should have made more checks on the man,
given his depression.
64. My investigators were unable to talk to one officer as he was on
extended sick leave following an operation. However, the other officer
described his relationship with the man. He said that staff built up a
good rapport with the man, enabling him to talk to them about the
things that bothered him. Staff working in the visits area took his
mother’s age and infirmity into account and used to make sure she was
given an appropriate table to one side. Staff had also been supportive
of his application for temporary release to see his mother in a nursing
home. The man had been relieved when the self harm monitoring form
was closed in 2005 as he did not want to leave Jubilee.
65. The officer felt that the man’s death had come out of the blue. He was
upset that the man had not spoken to him before he went on leave. He
said that, if there was something troubling the man, he would have
taken the opportunity to help him. He said that several of the officers
who worked on Jubilee knew the man well and had wanted to go to his
funeral. But none had been asked by senior managers if they wished
to attend. When they had made enquiries, the view was expressed
that the man’s family might not have wanted them there. Nonetheless,
the members of staff who had attended the funeral were there because
of their position in the prison, not because they knew the man. At the
time, this had caused some hurt amongst officers in Jubilee House.
ISSUES
66. Although the man was largely cheerful, telling jokes and making light of
his situation, it is also clear that he could quickly become depressed
and feel low. My investigators’ interviews with prisoners who were
close to the man reveal a person who was preoccupied by fears about
his mother’s ill health, and what the future held for him if he was
prevented from returning to his home area. To the man his home was
much more than just a place where he lived. His identity was bound up
there with deep family ties. He had never lived anywhere else. His
letter to Inside Time showed the issues he was wrestling with, and that
he was unable to see a way forward. Yet the stark reality was that his
victim was also his neighbour. The dispute between them which
culminated in the man’s imprisonment had not only remained
unresolved, it was very much at the forefront of his mind.
67. The man suffered from ill health. He was taking a number of
prescribed drugs for depression, diabetes, coronary and respiratory
problems, and alluded to staff on several occasions about the
possibility of dying in prison. His medical record contained comments
that his prognosis was poor. His depression, which pre-dated his
imprisonment, may have made him more susceptible when he was
feeling low.
68. Jubilee House provided the man with positive and supportive
relationships with prisoners and staff who provided acceptance and a
listening ear. I have been impressed by the consistently positive
comments prisoners made about Jubilee House staff: on their
approachability, their willingness to listen and to help them deal with
problems or issues as they arose, and the way they treat prisoners as
individuals. My investigators noted the open and relaxed atmosphere
of the house blocks they visited, and that staff/prisoner relationships
appeared excellent. It was commendable that the prisoner with whom
the man was friends, and had been moved to another house block,
was allowed to visit the man even though they were in different house
blocks. This showed a caring attitude towards the man and a
recognition that friendships between prisoners are important. This I
consider to have been good practice.
69. I am concerned that few of the prisoners my investigators spoke to
knew the night staff by sight. Indeed the night patrol OSG, who was on
duty the night before the man’s body was discovered, said at interview
that he rarely had verbal contact with the prisoners on Jubilee House.
He did not feel he needed to know their names or speak to them unless
there was a problem. He could not recognise any of the prisoners by
sight including the man. This was despite the fact that the man had
been there for over a year, turnover was low, the unit only held 40
prisoners, and the night patrol OSG worked there regularly. It may well
be that the residents of Jubilee House pose few problems or risks but,
as the man’s death has shown, even the most ‘compliant’ prisoner can
be a troubled individual. The task of building an effective rapport
between staff and prisoners is not solely for those who work in the day
time.
70. On the morning that the man died, it was realised that the video
machine linked to the CCTV system in Jubilee House had not been
switched on, and there was no visible evidence of night checks being
carried out. The electronic records from the pegging clock showed no
trace of the pegging point on the first floor being activated. However, a
couple of prisoners recalled being woken up after having their cell light
turned on by the night officer. Nevertheless, in light of the apparent
failure of the system, it would be sensible for the Governor to arrange a
maintenance check of all the pegging equipment.
71. My investigators learned that the CCTV system was self managed on
Jubilee. The security department within the prison did not have an
overview of its use. I am pleased that, since the man’s death, written
procedures have been developed concerning its operation.
72. Those who saw the man after he had died confirmed that his arm had
been resting on his locker and he appeared to be crouching. Although
the officer who found the man could not specifically remember seeing
him, he was certain that there was nothing in the man’s cell that had
attracted his attention as out of the ordinary. CCTV footage of the
officer checking the cells does not reveal anything untoward. It may be
that the officer saw part of the man’s arm resting on his locker and took
this as sufficient confirmation that he was present and awake. The
purpose of counting the unit at that time of the morning was to
ascertain that all prisoners were accounted for, so that the prison could
be unlocked for the day’s activities. I would only have expected the
officer to seek oral confirmation of the man’s presence if he had been
out of sight, for example in the toilet.
73. After the alarm was raised, staff acted quickly and efficiently to handle
the aftermath. The SO, the first member of staff to be present,
decided that it was futile to attempt resuscitation as the man was
clearly dead. However, healthcare staff attempted to administer
oxygen and start cardio pulmonary resuscitation even though rigor
mortis was evident. The clinical reviewer established that nursing staff
felt obliged to pursue resuscitation. The clinical reviewer has made a
recommendation on this matter which I endorse.
74. The PCT should review its resuscitation policy, to ensure that
their staff are not in the invidious position of having to perform it
in inappropriate circumstances.
75. Guys Marsh’s Family Liaison Officer was fully trained to carry out her
role and I understand that she provided an effective link between the
man’s family and the prison. It is unfortunate however, that staff from
Jubilee House were not offered the opportunity to pay their respects by
attending the man’s funeral if they wished, subject to the wishes of his
family. My investigators discussed this with the Governor who
expressed his regret and accepted that the issue could have been
handled more sensitively.
76. In sum, I do not think that the man’s death could reasonably have been
predicted. However, his death is a reminder that even prisons like
Guys Marsh must be alert to the dangers of suicide and self-harm.
Sadly, even the good staff-prisoner relationships which I have been
pleased to record and acknowledge in this report are no guarantee that
a prisoner will not try to end his life.
RECOMMENDATIONS
The PCT should review its resuscitation policy, to ensure that their staff
are not in the invidious position of having to perform it in inappropriate
circumstances.